LICEO DE CAGAYAN UNIVERSITY

R.N.P. Blvd., Carmen, Cagayan de Oro City

COLLEGE OF NURSING

A Case Study Jun Brian Cuarteros

With

Submitted to:

Mrs. Anecia A. So, RN

Clinical Instructor

As Partial Requirement for NCM501202

Submitted by:

Ramyr R. Ociones
September 28, 2007 1

I. Introduction Overview of the Case II. Health History a. b. c. d. Profile of Patient Family and Personal Health History History of Present Illness Chief Complain III. Developmental Data IV. Medical Management V. Pathophysiology with Anatomy & Physiology VI. Nursing Assessment (System Review & Nursing. Assessment II) VII. Nursing Management a. b. Ideal Nursing Management (NCP) Actual Nursing Management (SOAPIE) VIII. Health teachings IX. Referrals & Follow-up X. Prognosis XI. Evaluation XII. Documentation a. Documentation of Evidence of Care for 1 week rotation b. Bibliography

I.

INTRODUCTION Overview of the Case Any part of the lower gastro-intestinal tract is susceptible to acute inflammation caused by bacterial, viral or fungal infection. Two such situations are appendicitis and diverticulitis. Appendicitis is inflammation of the appendix. It is thought that appendicitis begins when the opening from the appendix into the cecum becomes blocked. The blockage may be due to a build-up of thick mucus within the appendix or to stool that enters the appendix from the cecum. The mucus or stool hardens, becomes rock-like, and blocks the opening. This rock is called a fecalith (literally, a rock of stool). At other times, the lymphatic tissue in the appendix may swell and block the appendix. Bacteria which normally are found within the appendix then begin to invade (infect) the wall of the appendix. The body responds to the invasion by mounting an attack on the bacteria, an attack called inflammation. (An alternative theory for the cause of appendicitis is an initial rupture of the appendix followed by spread of bacteria outside the appendix. The cause of such a rupture is unclear, but it may relate to changes that occur in the lymphatic tissue that line the wall of the appendix.) If the inflammation and infection spread through the wall of the appendix, the appendix can rupture. After rupture, infection can spread throughout the abdomen; however, it usually is confined to a small area surrounding the appendix (forming a peri-appendiceal abscess). Sometimes, the body is successful in containing ("healing") the appendicitis without surgical treatment if the infection and accompanying inflammation do not spread throughout the abdomen. The inflammation, pain and symptoms may disappear. This is particularly true in elderly patients and when antibiotics are used. The patients then may come to the doctor long after the episode of appendicitis with a lump or a mass in the right lower abdomen that is due to the scarring that occurs during healing. This lump might raise the suspicion of 3

cancer. The main symptom of appendicitis is abdominal pain. The pain is at first diffuse and poorly localized, that is, not confined to one spot. (Poorly localized pain is typical whenever a problem is confined to the small intestine or colon, including the appendix.) The pain is so difficult to pinpoint that when asked to point to the area of the pain, most people indicate the location of the pain with a circular motion of their hand around the central part of their abdomen. As appendiceal inflammation increases, it extends through the appendix to its outer covering and then to the lining of the abdomen, a thin membrane called the peritoneum. Once the peritoneum becomes inflamed, the pain changes and then can be localized clearly to one small area. Generally, this area is between the front of the right hip bone and the belly button. The exact point is named after Dr. Charles McBurney--McBurney's point. If the appendix ruptures and infection spreads throughout the abdomen, the pain becomes diffuse again as the entire lining of the abdomen becomes inflamed. Nausea and vomiting also occur in appendicitis and may be due to intestinal obstruction.

II.

HEALTH HISTORY a. Profile of Patient Cuarteros, Jun Brian February 25, 1989 Jagna, Bohol 18 Male 55 58 kg. Single Roman Catholic Filipino Deceased Cuarteros, Carmela Brg. 13, Mabini Burgos, Cagayan de Oro City Foods & Drugs September 9, 2007 1:00 AM Abdominal Pain Acute Appendicitis

Patients Name: Birth Date: Birthplace: Age: Sex: Height: Weight: Status: Religion: Nationality: Fathers Name: Mothers Name: Address: Allergy: Date of Admission: Time of Admission: Chief Complaints: Admitting Diagnosis: Vital Signs: Temperature: Pulse Rate: Respiratory Rate: BP:

38.9 C 95 bpm 32 cpm 140/70 mmHg

b.

Family and Personal Health History

Jun Brian Cuarteros, the youngest in the family who was diagnosed of having a Acute Appendicitis admitted at Northern Mindanao Medical Center lasts September 9, 2007. According to my interview with him it was his first time to be admitted at the hospital. c. History of Present Illness

My patient was Jun Brian Cuarteros, he was admitted at Northern Mindanao Medical Center on September 9, 2007 at 1:00 a.m. and his condition started a day prior to admission as onset of acute appendicitis with abdominal pain. d. Chief Complaint

A case of my patient, Jun Brian Cuarteros, was due to abdominal pain.

III.

DEVELOPMENTAL TASK

ERIK ERICKSONS THEORY OF PSYCHOSOCIAL DEVELOPMENT Adolescence: Intimacy vs. Isolation Intimate relationship with another person Commitment to work and relationships Impersonal relationships avoidance of relationship, career, or lifestyle commitments JEAN PIAGETS THEORY OF COGNITIVE DEVELOPMENT Piaget's Cognitive Development: Formal Operations Phase Uses rational thinking Reasoning is deductive and futuristic

IV.

MEDICAL MANAGEMENT

DOCTORS ORDER September 10, 2007 Laboratory Results > Temperature every 2 hours

RATIONALE

> To monitor patients condition if there is an improvement or if there is a change to prevent further complications. During this period of time, potentially fatal complications may develop.

> NPO

> Maintained as ordered.

> Intake and Output every 4 > To know if the patient has a normal fluid hours intake and output. To know for normal kidney functioning and for laboratory purposes. > IVF follow up #3 D5LR I L @ > Fluids are required to replace losses, to 30 gtts/min prevent patient dehydration. It aids also for mobilization of secretion. > Transfer IV site to Left Arm > To change the swelling site because of back flow of blood. > Continue medications > Compliance of medications gives early recovery. > Ambulate > Early ambulation helps the patient from faster recovery.

September 11, 2007 > Temperature every 2 hours > To monitor patients condition if there is an improvement or if there is a change to prevent further complications. During this period of time, potentially fatal complications may develop. 9 > Diet As Tolerated > Serves as transition to the regular diet; is a

September 8, 2007 Complete Blood Count Result White Cell Count Red Cell Count Hemoglobin Hematocrit MCV MCH MCHC RDW LV PDW MPV Differential Count Lymphocytes Neutrophil Monocyte Eosonophil Basophils Platelet Count 13.6 74.6 10.7 1.0 0.1 240,000 17.4 48.2 % 43.4 76.2 % 4.5 10.5 % 0 7.0 % 0.0 2.0 % 150,000 400,000 mm 12.7 10.0 8.9 17,500 5.20 15.7 45.4 87.3 30.2 34.6 Expected Values 5,000 10,000 4.20 5.40 million 12.0 16.0 gm/dl 37.0 47.0 vol. % 82.0 98.0 fL 27.0 31.0 pg 31.5 35.0 g/dl 12.0 17.0 % 9.0 16.0 fL 8.0 12.0 fL

Urinalysis Color Clarity pH Specific Gravity Protein Glucose yellow hazy 7.5 1.010 negative negative

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V.

PATHOPHYSIOLOGY WITH ANATOMY & PHYSIOLOGY

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Anatomy & Physiology

The appendix is a small finger-like projection that comes off the cecum of the large intestine and has no apparent function in the human. When the opening in the sac is blocked, it leads to an inflammation of the appendix called appendicitis. This condition occurs most commonly in the young, between childhood and young adulthood. Appendicitis is an emergency condition and requires urgent surgical removal of the appendix. The appendix is a narrow, muscular tube. One end
is attached to the first part of the large intestine, while the other end is closed. The position of the appendix in the body can vary from person to person. An average adult appendix is about 4 inches (10cm) long. However, it can vary in length from as less as an inch to 8 inches. Its diameter is usually about about 6 to 7 mm. The function of the appendix is unknown. Foods that have not been digested tend to move into the appendix and are forced out again by the contractions of appendix. In herbivorous animals like cow and goat, the appendix can function. In man, this has become what is called as a vestigial organ (an organ that is no more required). The vermifom appendix or appendix in short, is a small part of the bowel or intestine. It is situated on the right side of the abdomen at the junction of the small and large intestines. It is a small narrow sac approximately 10 cm long and 1 cm wide. The appendix is a vestigial organ, that is, it serves no useful purpose.

The appendix is a small projection that develops from a portion of the large intestine called the cecum. As the appendix develops it lengthens and the tip can be found in almost any position about the cecum.

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Pathophysiology Predisposing factors: Age Gender Lifestyle Precipitating factors: Infections Appendicitis

Obstruction of the narrow appendiceal lumen

Obstruction has many sources, including fecaliths, lymphoid hyperplasia (related to viral illnesses such as upper respiratory infections, mononucleosis, or

Gastroenteritis gastrointestinal parasites, foreign bodies, and Crohn's disease

Continued secretion of mucus from within the obstructed appendix results in elevated intraluminal pressure,

Leading to tissue ischemia, over-growth of bacteria, transmural inflammation, appendiceal infarction, and possible perforation

Inflammation may then quickly extend into the parietal peritoneum and adjacent structures

s/s: epigastric pain, vomiting, anorexia, fever

Complications: wound infections, intra-abdominal abscess, intestinal obstruction, and prolonged ileus

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VI.

NURSING SYSTEMS REVIEW CHART

Date: 09-09-07

Name: Jun Brian Cuarteros Vital Signs: Pulse: 95 bpm Height: 55 Bp: 140/70 mmHg Weight: 58 kg. RR: 32 cpm

Temp: 38.9 C

EENT [ ] impaired vision [ ] blind [ ] pain redden [ ] drainage [ ] gums [ ] hard of hearing [ ] deaf [ ] burning [ ] edema [ ] lesion [ ] teeth [ ] assess eyes ears nose [ ] throat for abnormality [x] no problem RESP: [ ] asymmetric [x] tachypnea [ ] barrel chest [ ] apnea [ ] rales [ ] cough [ ] bradypnea [ ] shallow [ ] rhonchi [ ] sputum [ ] diminished [ ] dyspnea [ ] orthopnea [ ] labored [ ] wheezing [ ] pain [ ] cyanotic Assess resp. rate, rhythm, pulse blood breath sounds, comfort [x] no problem CARDIOVASCULAR: [ ] arrhythmia [ ] tachycardia [ ] numbness [ ] diminished pulses [ ] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] murmur [ ] tingling [ ] absent pulses [ ] pain Assess heart sounds, rate rhythm, pulse, blood pressure, circ., fluid retention, comfort [x] No problem GASTROINTESTINAL TRACT: [ ] obese [ ] distention [ ] mass [ ] dysphagia [ ] rigidity [x] pain assess abdomen, bowel habits, swallowing, bowel sounds, comfort [x] no problem GENITO URINARY AND GYNE [ ] pain [ ] urine [ ] color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] nucturia Assess urine frequency, control, color, odor, [ ] gyne bleeding [ ] discharge [x] no problem NEURO: [ ] paralysis [ ] stuporus [ ] unsteady [ ] seizure [ ] lethargic [ ] comatose [ ] vertigo [ ] tremors [ ] confused [ ] vision [ ] grip Assess motor, function, sensation, LOC, grip, gait, coordination, speech [x] no problem MUSCULOSKELETAL and SKIN: [ ] appliance [ ] stiffness [ ] itching [ ] petechiae [ ] rashes [ ] drainage [ ] prosthesis [ ] swelling [ ] lesion [ ] poor turgor [ ] cool [ ] flushed [ ] atrophy [ ] pain [ ] ecchymosis [ ] diaphoretic Assess mobility, motion gait, alignment, skin color, texture, turgor, integrity [x] no problem

fast breathing pain at the surgical site

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VII.

NURSING MANAGEMENT a. Ideal Nursing Management (NCP)

NURSING DIAGNOSIS: Sleep Pattern Disturbances Risk factors may include Internal factors: illness, psychologic stress, inactivity External factors: environmental changes, facility routines Changes in activity pattern Possibly evidenced by Reports of difficulty in falling asleep/not feeling well-rested Interrupted sleep, awakening earlier than desired Change in behavior/performance, increasing irritability DESIRED OUTCOMES/EVALUATION CRITERIACHILD WILL: Sleep (NOC) Report improvement in sleep/rest pattern. Verbalize increased sense of well-being and feeling rested.

ACTIONS/INTERVENTIONS Sleep Enhancement (NIC) Independent Provide afghan. Establish environment. new sleep comfortable bedding and Increases

RATIONALE

comfort

for

sleep

and

some of own possessions; e.g., pillow, physiologic/psychologic support.

routine When new routine contains as possible, stress and related anxiety may be reduced, enhancing sleep.

incorporating old pattern and new many aspects of old habits as

Match with roommate who has similar Decreases likelihood that night owl 15

sleep patterns and nocturnal needs.

roommate may delay clients falling asleep or create interruptions that cause awakening.

Encourage some light physical Daytime activity can help client activity during the day. Make expend energy and be ready for sure client stops activity several nighttime hours before bedtime individually appropriate. bedtime may sleep; act as however, stimulant, as continuation of activity close to delaying sleep. Promotes Promote bedtime comfort regimens; effect. e.g., warm bath and massage, a glass of warm milk, wine/brandy at bedtime. Helps induce sleep. Instruct in relaxation measures. Provides atmosphere conductive to Reduce noise and light. sleep. Repositioning in turning. May heave fear of falling because of Lower bed and position one side change in size and height of bed. against wall when possible. Collaborative May be given to help client alters areas of a relaxing, soothing

Encourage position of comfort, assist pressure and promotes rest.

Administer sedatives, hypnotics with sleep/rest during transition period caution as indicated. from home to new sitting.

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NURSING DIAGNOSIS: Risk for Imbalanced Body Temperature Risk factors may include Exposure to cool environment Use of medications, anesthetic agents Extremes of age, weight; dehydration Possibly evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis] DESIRED OUTCOMES/EVALUATION CRITERIACHILD WILL: Thermoregulation (NOC) Maintain body temperature within normal range.

ACTIONS/INTERVENTIONS Temperature Regulation (NIC) Independent Assess warming environmental blankets,

RATIONALE

temperature Manipulating ambient air around client room

and modify as needed; e.g., provide will prevent heat loss. increase temperature. Provide cooling measures for client Cool irrigations, exposure of skin with preoperative or postoperative surfaces to air, cooling blanket may temperature elevations. be required to decrease temperature. Increase ambient room Minimizes client heat loss when prepared for transfer.

temperature (e.g., to 78F or drapes are removed and client is 80F) at conclusion of procedure.

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Collaborative Monitor temperature throughout Continuous warm/cool humidified inhalation anesthetics are used to main tree. Malignant Hyperthermia Precautions (NIC) Respond promptly to symptoms of Prompt recognition and immediate malignant hyperthermia (MH); i.e., action to control temperature is rapid temperature elevation/persistent necessary high fever: to prevent serious complications/death. solution lavage of body humidity and temperature balance within the tracheolbronchial

intraoperative phase.

Provide iced saline to all body Iced surfaces and orifices;

surfaces and cavities will reduce body temperature.

Obtain dantrolene (Dantrium) for IV Immediate administration per protocol. intense associated hyperthermia.

action catabolic with

to

control process malignant

temperature is necessary to prevent

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NURSING DIAGNOSIS: Acute Pain Risk factors may include Distention of intestinal tissues by inflammation Presence of surgical incision Possibly evidenced by Reports of pain Facial grimacing, muscle guarding; distraction behaviors Autonomic responses DESIRED OUTCOMES/EVALUATION CRITERIACHILD WILL: Pain Level (NOC) Report pain relieved/controlled. Appear relaxed, able to rest/sleep appropriately.

ACTIONS/INTERVENTIONS Pain Management (NIC) Independent Assess pain, noting

RATIONALE

location, Useful in monitoring effectiveness of

characteristics, severity (0-10 scale). medication, progression of healing. Investigate and report changes in pain as appropriate. Provide accurate, honest information Being informed about progress of to client. situation support, anxiety. provides helping to emotional decrease

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Keep at rest in semi-Fowlers position.

Gravity

localizes

inflammatory

exudates into lower abdomen or pelvis, relieving abdominal tension, which is accentuated by supine position. Encourage early ambulation. Promotes normalization of organ function; e.g., stimulates peristalsis and passing of flatus, reducing abdominal discomfort. Refocuses abilities. Collaborative Keep initially. NPO/maintain NG suction Prompt recognition and immediate action to control temperature is necessary to prevent serious complications/death. Relief of pain facilitates cooperation with other therapeutic interventions; e.g., ambulation, pulmonary toilet. abdomen Soothes and relieves pain through periodically during initial 24-48 hour as desensitization of nerve endings. Place ice bag on appropriate. attention, promotes

Provide diversional activities.

relaxation, and may enhance coping

Administer analgesics as indicated

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b.

Actual Nursing Management (SOAPIE)

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S O S O A A P

Dili ko katulog kaayo, lisod ko og katulog as verbalized by the patient. Sakit akong tiyan diri dapit insomnia kilid as verbalized by the patient. Sleep maintenance sa akong Facial grimace Dark circles under eyes Guarding Restlessness Sleep pattern disturbance related to fatigue and body temperature Restlessness Alteration in comfort pain related to distension of intestinal tissues by inflammation Long term: At the end of 24 hours, the patient will be able to report Long term: At sleep/rest an hour, improvement in the end ofpattern. the patient will be able to response to interventions/teaching and action performed. Short term: At the end of 8 hours of rendering nursing intervention, the patient Short term: to verbalize increase sense of well-being nursing intervention, the will be able At the end of 30 minutes of rendering and feeling rested. patient will be able to verbalize relief/control of pain. Provide comfortable bedding and some of own possessions; e.g., pillow, afghan. Assess pain noting location, characteristics and intensity. (0-10 scale). o Helps evaluate degree of discomfort. Increases comfort for sleep and physiologic/psychologic support. Provide accurate, honest information to patient/SO. Keep at rest in Establish new sleep routine incorporating old pattern and new semi-Fowlers position. environment. informed about progress of situation provides emotional o Being o When new routine contains as many aspects of old habits as support, helping to decrease anxiety. Gravity localizes

P I

possible, stress and related lower abdomen reduced, enhancing inflammatory exudate into anxiety may be or pelvis, relieving sleep. abdominal tension, which is accentuated by supine position. Instruct in or cold compress when indicated. Apply hot relaxation measures. o Helps induce sleep. o Reduces pain. Encourage position of comfort, assistrub, repositioning the patient. Provide comfort measures e.g. back in turning. o Repositioning alters areas of pressure and promotes rest. o Promotes relaxation and may enhance coping abilities.

E E

After rendering nursing intervention, the patient was able to verbalized After rendering nursing intervention, the patient was able to verbalized increase sense of well-being and feeling rested. relief/control of pain.

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VIII.

HEALTH TEACHINGS

S O

Baho na kaayo ko, gusto nako maligo as verbalized by the patient. Body odor Dryness of hair & scalp Foul odor of the mouth

Self-care deficit: bathing/hygiene related to pain discomfort Long term: At the end of the shift, the patient will be able to perform self-care activities within level of own ability.

Short term: At the end of 30 minutes of rendering nursing intervention, the patient will be able to demonstrate techniques/lifestyle changes to meet own needs. Involve client in formulation of plan of care at level of ability. o Enhances sense of control and aids in cooperation and maintenance of independence. Provide and promote privacy, including during bathing/showering. o Modesty may lead to reluctance to participate in care or perform activities in the presence of others.

Shampoo/style hair as needed. Provide/assist with manicure. o Aids in maintaining appearance. Shampooing may be required more/less frequently than bathing schedule.

Encourage/assist with routine mouth/teeth care daily. o Reduces risk of gum disease/tooth loss, enhances oral health, and promotes proper fitting and use of dentures.

After rendering nursing intervention, the patient was able demonstrated techniques/lifestyle changes to meet own needs.

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MEDICATIONS

> Advised and encouraged patient or family to give the patient paracetamol when she has fever. > Do not give patient more than 5 doses in 24 hours unless prescribed by physician.

EXERCISE

> Take some rest to prevent stress and other complications. > Instruct the patient to do frequent ambulation, do ROM exercises and deep breathing exercises to promote blood circulation and fast healing.

TREATMENT

> Instruct the patient to continue for compliance of medication regimen. > Instruct the patient to increased fluid intake to promote regain of fluid and electrolyte balance.

OUT-PATIENT (Check-up)

> Advised the patient to visit to the nearest hospital for further check-up. > Instruct the patient to call his physician if he will experience any unusualities.

DIET

> Encourage the patient to eat rich in high protein such as meat, fish, and eggs for early wound healing

IX.

REFERRALS & FOLLOW-UP

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To allow continuous monitoring of the patients healing progress, patient was encouraged to consult her doctor 2 weeks after discharge for follow-up check up of her general condition. This will ensure thorough follow up of her condition and prevention of potential complications. Apart from this, patient was advised to increase fluid intake, make sure that proper hand washing is practiced before and after eating.

X.

PROGNOSIS

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Patients with acute appendicitis usually progress especially when it is not yet to its mere complication. The rate of progression depends on the underlying diagnosis, on the successful implementation of secondary preventative measures, and on the individual patient. If the patient is untreated the prognosis becomes worst and poor. In the case of our patient, as he undergone tough treatment at Northern Mindanao Medical Center, his prognosis is considered as good. As evidenced by tolerating slowly lessen the abdominal pain and maintaining increase of fluid and electrolyte balance.

XI.

EVALUATION

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At the end of my hospital duty, I as a student nurse was able to render care to my patient to help him resolve his problem regarding health. Through observing the patients status, I was able to identify some problems during my assessment. Because of a couple of interventions or health teachings applied and imparted to the patient, I was able to render his needs on his problem; alleviated pains felt by the patient due to the effects of the abdominal pain or appendicitis; and even have improved his sleeping/resting pattern. Patient was willing to pursue his medical therapy just to promote health and wellness for the betterment of his condition. During the treatment, the patient was able to develop or enhance health awareness on his disease and with this knowledge instilled to his mind, he was then aware on how the disease was transmitted and what are the proper ways or interventions done just to minimize or prevent this disease from getting worst. I have also made the patient realize the importance of completing the course of therapy by taking the medicines prescribed or ordered to him by his physician. In addition, eating healthy or nutritious foods that were prescribed to him by the health providers was further been explained to him especially the benefits he will gain in eating these nutritious foods. In general, the patient was very cooperative to what health measures administered to him by the health providers. Moreover, these several interventions given to the patient made his body functions different than as before.

XII.

DOCUMENTATION

a.

Documentation of Evidence of Care for 1 week rotation:

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b. Bibliography:

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Black, Joyce M. 1993. Medical-Surgical Nursing. - A Psychologic Approach. 4th Edition. W.B Saunders Company: Philadelphia, Pennsylvania,USA. Smeltzer, Suzanne C.et al.2004. Medical Surgical Nursing. - 10th Edition. Lippincott Williams and Wilkins: Philadelphia Price, Sylvia A. 1997. Pathophysiology: Clinical Concepts of Disease Processes. 5th Edition. Mosby Year Book, Inc: United States of America Carpenito, Lynda Juall.2000. Nursing Diagnosis: Application to Clinical Practice. 8th Edition. Lyndal Juall Carpenito: United States of America. Pillitteri, Adele. 2003. Maternal and Child Health Nursing. 4th Edition. Wolter Kluwer Company: Hong Kong. Doenges, Marilynn E. 2006. Nurses Pocket Guide. F. A Davis Company: Philadelphia.

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